DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  618

                                                Instituted on:    22.11.2017

                                                Decided on:       24.05.2018

Nishu Gupta aged about 39 years wife of Sh Vikas Gupta, resident of H.NO.157, Captain Karam Singh Nagar, Sunam Road, Sangrur.

                                                        …Complainant

                                Versus

1.             The Oriental Insurance Company Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh  through its Branch Manager.

2.             M.D. India Health Care Services Pvt. Ltd.  Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali through its Managing Director.

3.             Director, Health and Family Welfare Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.

4.             Deputy Commissioner, District Administrative Complex, Opposite Bus Stand, Sangrur.  

                                                        ..Opposite parties.

For the complainant  :       Shri Sanjeev Goyal, Adv.

For Opp.Party No.1to2:    Shri Ashish Garg, Adv.

For Opp.Party No.3&4:     Ms. Amandeep Kaur, Adv.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

Order by : Sukhpal Singh Gill, President.

1.             Smt. Nishu Gupta, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant being a government employee is working as Steno in the office of Deputy Commissioner, Sangrur, and as such she along with his family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09814529419 for the period from 1.1.2016 to 31.12.2016.   The case of the complainant is that during the subsistence of the insurance policy, the complainant was diagnosed with dreaded disease of breast cancer and was immediately taken to Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, where she got treatment from 1.6.2016 to 7.10.2016 and spent an amount of Rs.3,78,180/- on her treatment and thereafter submitted all the bills to the OPs for releasing the amount, but the OPs number 1 and 2 released only total amount of Rs.1,96,967/- to the complainant against the insurance amount of Rs.3,00,000/-, whereas the complainant had spent an amount of Rs.3,78,180/-.  Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.1,03,033/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by Ops number 1 and 2, legal objections are taken up on the grounds that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable. On merits, it is admitted that the policy in question was issued in favour of the Govt. of Punjab for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions of the policy under which a sum of Rs.3,00,000/- was insured per family on floater basis.   It is further stated that as per the schedule, the liability of the company is to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room.  It is admitted that the complainant remained admitted in Rajiv Gandhi Cancer Institute, Delhi from 1.6.2016 to 4.6.2017, where she was diagnosed for lump in breast and the complainant submitted the bill for Rs.1,44,540/- for reimbursement, but the company paid Rs.28,736/- as per package rates.  The complainant again remained admitted in Rajiv Gandhi Cancer Institute, Delhi from 28.6.2016 to 30.6.2016 where she spent an amount of Rs.57,117/-, but the company paid only an amount of Rs.28,459/- as per package rates.  It is further admitted that the complainant remained again admitted in the said hospital thereafter so many times in Rajiv Gandhi Cancer Institute Delhi and the amount was accordingly paid as per the package rates.  It is submitted in the reply that the amount has been paid to the complainant as per the company rates according to law. It is further averred in the reply that if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee.

3.             In reply filed by Ops number 3 and 4, legal objections are taken up on the grounds that the present complaint is premature and that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint and that the complainant has got no locus standi to file the present complaint.  On merits, it is stated that the OP number 3 and 4 have no liability to reimburse the medical claim/bills as alleged by the complainant. It is stated that as per the policy, the liability to pay the claim is of the insurance company.  The other allegations levelled in the complaint have been denied in toto.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-12 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 to 2  has produced Ex.OP1to2/1 to Ex.OP1to2/5 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 3 and 4 has produced Ex.OP3&4/1 to Ex.OP3&4/6 and closed evidence.  

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

6.             It is an admitted fact between the parties that the complainant being a Punjab Government employee was working as Steno in the office of Deputy Commissioner, Sangrur and as such she along with her family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09814529419 for the period from 1.1.2016 to 30.12.2016.  It is also not in dispute that during the subsistence of the insurance policy the complainant was diagnosed  with dreaded disease of breast cancer and was immediately taken to Rajiv Gandhi Cancer Institute and Research Centre, Delhi on different dates i.e. 1.6.2016 to 7.10.2016 and spent an amount of Rs.3,78,180/-, as is evident from the copies of the bills produced on record.  It is also the admitted case of the parties that though the complainant submitted the total bills for Rs.3,78,180/-, but the OPs paid only an amount of Rs.1,96,967/-, despite her best efforts.  Now, the case of the complainant is that despite the fact the complainant submitted the bills to the Ops number 1 to 2 for reimbursement to the tune of Rs.3,78,180/-, but the OPs paid only an amount of Rs.1,96,967/- and withheld the remaining claim amount to the tune of Rs.1,03,033/- without assigning any reason thereof. The complainant has produced on record the medical record including the copies of the bills as Ex.C-1 to Ex.C-12, as such it is contended by the learned counsel for the complainant that the claim to the tune of Rs.1,03,033/- has wrongly been withheld by the OPs.  On the other hand, the stand of the OPs number 1 to 3  is that the due claim amount to the tune of Rs.1,96,967/- has already been paid as per the prescribed rates and no further amount is payable. But, we are unable to accept such a contention of the learned counsel for the OPs that no more amount is payable as the complainant has spent an amount of Rs.3,78,180/-, whereas the OP number 1 and 2 have paid only an amount of Rs.1,96,967/- only to the complainant. Since the case of the complainant is a breast cancer disease, we find that that the OPs number 1 and 2 are liable to pay to the complainant further an amount of Rs.1,03,033/- making it total claim to the tune of Rs.3,00,000/- as insured under the insurance policy in question.  

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 1 to 2  to pay to the complainant an amount of Rs.1,03,033/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 22.11.2017 till realisation.  We further order the OPs number 1 to 3 to pay to the complainant an amount of Rs.5,000/- in lieu of consolidated amount of compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses.

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 24, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member

                                                        (Vinod Kumar Gulati)

                                                                   Member